chapter 15 Study guide

What is the priority when caring for a patient with an indwelling urinary catheter?

Monitor the drainage system, including urine amount, color, odor, and tubing for kinks, while watching for complications such as infection.

When should an indwelling urinary catheter be removed?

As soon as it is medically able to be removed.

After removal of an indwelling urinary catheter, within what time should the patient void?

Within 8 hours.

Why must the nurse continue monitoring a patient after catheter removal even if the patient initially appears well?

A urinary tract infection may not become apparent until about 2 days after catheter removal.

Which catheter is particularly useful for a patient with prostate problems?

A Coudé catheter.

What is an easy way to remember the purpose of a Coudé catheter?

Coudé = curved catheter associated with patients who have prostate problems.

What type of catheter is commonly used as an indwelling urinary catheter?

A Foley catheter.

What is a condom catheter?

An external urinary catheter commonly used for male patients with urinary incontinence.

What is PureWick?

A female external urinary catheter.

Where does a suprapubic catheter enter the urinary system?

Through the abdomen into the bladder.

What is one major goal of intermittent self-catheterization for a patient with neurologic impairment?

Promoting independence in urinary elimination.

What should the nurse teach a patient who performs self-catheterization?

Proper technique, signs of infection, and understanding of the catheterization process.

What is catheter irrigation used for?

To maintain catheter patency and help manage blockage or problems involving bladder drainage.

What is important when performing an open catheter irrigation?

Maintaining sterility.

Why is a closed intermittent catheter irrigation system useful?

It helps reduce contamination.

What must be done to the port before using a closed catheter irrigation system?

The port must be cleaned.

What is continuous bladder irrigation?

A closed continuous method of irrigating the bladder.

What is especially important to monitor during continuous bladder irrigation?

Correct urine output.

What is an NG tube?

A flexible, hollow tube passed through the nose into the stomach.

Why might a patient require an NG tube?

For removal of stomach contents, diagnostic purposes, administration of fluids or nutrients, prevention of abdominal distention/vomiting, or GI rest.

How should an NG tube be measured before insertion?

From the nose to the earlobe to the xiphoid process.

What is the most accurate method for confirming NG tube placement?

X-ray.

What should the nurse do if resistance is encountered during NG tube insertion?

Do not force the tube; stop and follow appropriate nursing procedure/policy.

What is the purpose of the air vent on a Salem sump tube?

It helps prevent the tube from adhering to the stomach mucosa or wall.

What is a Levin tube?

An NG tube with a single lumen.

What is the primary purpose of a small-bore feeding tube?

Providing enteral feeding; it is not used for suction.

What areas should the nurse assess when caring for a patient with an NG tube?

Mouth, nose, tube patency, and correct tube placement.

Why is mouth care important for a patient with an NG tube?

To maintain oral comfort and hygiene while the tube is in place.

Why should the nurse assess the patient's nose when an NG tube is present?

To monitor for irritation or other problems caused by the tube.

What is gastric lavage used for?

Certain poisoning situations and management of GI bleeding.

What is the purpose of gastric lavage?

To remove stomach contents and the solution used during the procedure.

What type of solution temperature is identified for gastric lavage in the PowerPoint?

Room-temperature solution.

What is gastric decompression?

Removal of air and fluid from the stomach to decrease distention and support GI mobility.

What type of suction is used for gastric decompression?

Intermittent suction.

What is gastric gavage?

Administration of fluids or nutrients through a gastric tube.

What is the minimum HOB elevation for gastric gavage according to the PowerPoint?

At least 30 degrees.

Why is patient positioning important during gastric gavage?

Appropriate positioning helps promote safe administration of the feeding.

What is dumping syndrome associated with in the PowerPoint?

Shock symptoms.

How should the nurse prepare a patient for NG tube removal?

Reassure the patient and explain that removal is generally less distressing than insertion.

Which NG-tube tasks should not be delegated to unlicensed assistive personnel according to the PowerPoint?

NG tube insertion, administering feedings, and NG tube removal.

What factors can promote normal bowel elimination?

Adequate diet and fiber, fluids, activity, privacy, and appropriate positioning.

What fluid intake range is listed in the PowerPoint for promoting bowel elimination?

2,000–3,000 mL.

What are hemorrhoids?

Swollen and inflamed veins in the anus and lower rectum.

Can hemorrhoids be internal or external?

Yes. They may be internal or external.

What should the nurse avoid using in a patient with hemorrhoids?

Rectal tubes and rectal thermometers.

What is flatulence?

Air or gas in the intestinal tract.

What problems can flatulence cause?

Abdominal distention and abdominal pain.

What are some causes of flatulence identified in the PowerPoint?

Beans, surgery, changes in abdominal peristalsis, and narcotics.

What device may be used to help relieve excessive intestinal gas?

A rectal tube, when appropriate.

What is an enema?

The instillation of a solution into the colon through the anus.

Why might an enema be administered?

To clean the colon, treat constipation, administer medication, or address fecal impaction.

What is an oil-retention enema used for?

Fecal impaction.

When might an enema be given before a procedure?

Before abdominal surgery, colonoscopy, or childbirth, when ordered/appropriate.

How far does the PowerPoint indicate the enema tube is inserted?

Approximately 3–4 inches.

What is fecal impaction?

A hardened collection of stool that becomes difficult to pass.

What is an ostomy?

An artificial opening called a stoma.

Can an ostomy be temporary or permanent?

Yes.

What is a colostomy?

A bowel diversion in which the stoma is created from the colon.

What is an ileostomy?

A bowel diversion in which the stoma is created from the ileum.

What is a urostomy?

A urinary diversion that allows urine to leave through a stoma.

How can you remember the difference between a colostomy and ileostomy?

Colostomy = colon; ileostomy = ileum.

Why can stool consistency differ between a colostomy and ileostomy?

The location of the stoma affects how much water is removed from intestinal contents before they leave the body.

What is one of the most important principles of ostomy pouch care?

Maintaining a proper seal around the stoma.

How much larger than the stoma should the pouch opening be according to the PowerPoint?

Approximately 1/16 inch larger than the stoma.

How should the stoma be cleaned?

With warm water.

Why is patient education important with ostomy care?

Each pouch change provides an opportunity to teach and reinforce proper self-care.

What additional support may be encouraged for a patient with an ostomy?

Support groups.

Can foods affect a patient's stool after an ostomy?

Yes. Foods can affect stool characteristics and odor.

A patient has an NG tube and the nurse encounters resistance during insertion. Which action is most appropriate?

Do not force the tube.

A patient has hemorrhoids and needs assistance with gas. Should the nurse insert a rectal tube?

No. The PowerPoint specifically states that rectal tubes should not be used with hemorrhoids.

A patient has a Coudé catheter. What condition would make this catheter particularly useful?

A prostate problem that makes catheterization difficult.

A patient has a small-bore feeding tube. Should the nurse connect it to suction?

No. The PowerPoint identifies the small-bore tube as a feeding tube rather than a suction tube.

A patient is receiving gastric gavage. What HOB position should the nurse maintain?

At least 30 degrees.

A patient has a new ostomy. How should the nurse size the pouch opening?

Approximately 1/16 inch larger than the stoma.

A patient is scheduled for an enema. What is the insertion depth identified in the PowerPoint?

Approximately 3–4 inches.

A patient has an ileostomy. Which part of the GI tract is the stoma connected to?

The ileum.

A patient has a colostomy. Which part of the GI tract is the stoma connected to?

The colon.

A patient has a urostomy. What is being diverted?

Urine.

A patient has continuous bladder irrigation. What nursing assessment is particularly important?

Accurate urine output.

A patient has had an indwelling catheter removed. What should the nurse monitor for next?

Whether the patient voids within 8 hours and for signs of urinary complications.